American Girl: How Young Is Too Young To Be Trans?

In October 2015, Nicole buckled in to her mom’s Prius, along with her older brother, mom, dad, and a bag full of her favorite dolls, for a three-hour drive to see a doctor about her new life.

Over the past 18 months, the 9-year-old had grown out her black curly hair from a crew cut to a flouncy bob just below her ears. She had traded in pants and overalls for pink and purple dresses covered in rhinestones. And she had changed her name, ditching the common boys name that now made her cringe to hear.

It had been a challenging time for Nicole’s parents, Kim and Andrew, whose conservative Christian circle of friends in Texas rejected the entire family after seeing the changes in this kid. Nicole was happier than she’d ever been, but the trip ahead still made her anxious. So, trying to calm her nerves, Kim switched on her daughter’s favorite book on tape, Hank the Cowdog, and stopped to get her kolaches, the Czech pastries that Central Texas is known for. Then she gave her an early birthday present: Next year, when she turned 10, they would get her a prized American Girl doll, just as they had for her older sister a decade earlier.

Puberty was just around the corner, and nobody knew exactly what it would bring for this sweet, lanky, and rapidly growing child who loved to sing. Which is why they were driving to Dallas, to a new clinic called Genecis, one of at least 16 centers in the US where psychologists, endocrinologists, and social workers help young kids who don’t fit in the tidy boxes of “boy” and “girl.”

Puberty was just around the corner, and nobody knew exactly what it would bring.

No clinics like Genecis existed in 2007, when 6-year-old Jazz Jennings became the youngest trans person to ever be interviewed on TV. Back then, Barbara Walters asked her what she would call herself. (“A girl,” she responded.) Back then, psychiatry’s official diagnosis for children like Jazz was “gender identity disorder.” Back then, though transgender teens and adults could see doctors for hormone treatments, the predominant way of treating small kids who were unhappy in the gender they were assigned at birth was to steer them toward accepting it.

Now, Jazz is just one of many trans kids visible in popular culture. This week, 8-year-old trans actor Jackson Millarker played a trans character on Modern Family, reportedly a first for network television. Before that was the TLC documentary Transgender Kids Camp, and the How to Be a Girl podcast. These kids' official diagnostic label has also changed, from “gender identity disorder” to the less stigmatizing — though still controversial — “gender dysphoria.”

Despite this broader understanding and acceptance, transgender teens — estimated to make up roughly 1.5% of all teenagers — are two to three times more likely than their peers to attempt suicide or experience serious depression.

The doctors who work at new “gender-affirming” clinics like Genecis say the best way to prevent these dire outcomes is to let young kids live out their gender identities however they wish — whether that’s as a boy, as a girl, or somewhere in between. They say that because gender identity is largely hardwired in the brain, kids as young as 3 can begin to articulate it, and that these kids end up happier, less anxious, and better adjusted socially the earlier we allow them to express the gender they feel themselves to be. For the small subset of kids who show a strong and consistent belief that they are a different gender, that means letting them “socially transition” to life as a full-time boy or girl.

But some doctors — as well as an unexpected mix of liberal academics, scientists, and religious conservatives — argue that we have no way of knowing with certainty which prepubescent kids who behave outside of gender norms will come to identify as trans, and which ones will not. Some worry that this approach could steer kids who are just going through a phase into a transgender “track” long before the kids know whether those feelings will really stick. Others say it reinforces outdated stereotypes — giving worried parents the false assurance that their girly boy is actually just a girl who was born in the wrong body. Conservative critics peg the increase in trans kids today to a dangerous new fad in parenting.

The most extreme members of each group have likened the other’s approach — whether pushing kids to identify as transgender or pushing them to repress their true gender identities — to “child abuse.” Unfortunately, there isn’t much hard data to help settle the debate: No study has looked at what happens later in life to kids who are allowed to socially transition before puberty.

Which leaves families like Nicole’s at a crossroads. While scientists carry out studies that will take many more years, a growing number of parents have to make decisions about their kids right now. Do they let their kids transition without knowing, for sure, that they’ll grow up to feel the same?

Nicole with her sister and her mom.

Ilana Panich-Linsman for BuzzFeed News

Nicole was born in 2006 in Austin. (“Nicole,” used in this story to protect her privacy, is her middle name.) Her biological mother had been a drug user, and her father was unknown. Child Protective Services took custody of the baby straight from the hospital.

Six months later, in a conservative suburb 20 miles away, Kim and Andrew were looking to adopt. They had used fertility drugs to conceive their oldest daughter, 12-year-old Olivia, and had later adopted a 6-year-old boy, WB. Kim had quit her job as a nurse to homeschool them and now wanted “just one more.”

Nicole had been placed with an adoptive Mexican family, but they sent her back after finding out that, although she was half Mexican, she was also half black. So the adoption agency asked Kim and Andrew if they could foster Nicole for the weekend before she was placed elsewhere.

“I said, ‘Yes, I’ll take the baby, but not for the weekend. If you want me to keep the baby, I want to keep the baby,’” Kim told me over root beers and Little Caesars pizza when I visited their home in July. “We knew who we were supposed to have.”

It’s OK, they thought — their new son didn’t need to like trucks any more than their daughter, who was bookish and always lost in her fantasy novels, needed to like makeup and high heels. Kim, who proudly does all the family’s sewing, cooking, and cleaning, disavows some gender norms herself: She lives in her cutoffs and Birkenstocks, and occasionally pulls out the combat boots left over from her military days.

Pediatricians told Kim and Andrew that Nicole’s interest in girl toys was just a phase and nothing to worry about. But some of their church friends and parents in their Christian homeschooling group were less sanguine, suggesting that the toddler should be steered toward more “appropriate” activities. They tried. “We were like, ‘Well, we know God gave you those parts for a reason. He’s got big things in store for you,’” Kim recalled.

For Nicole’s third, fourth, and fifth birthdays, her parents bought any boyish toys they could find — trains, cars, a Batman costume. But the cars were used to play house, with car moms and car dads, and Batman’s cape turned into a long-haired wig.

Ilana Panich-Linsman for BuzzFeed News

Although Kim and Andrew didn’t know it at the time, a similar debate was playing out among prestigious medical experts. In 2008, two of them spoke on NPR’s All Things Considered, in a 23-minute exchange that’s often cited by gender experts today. The segment focused on two young kids, raised as boys, who had for some time expressed strong preferences for stereotypically feminine toys and clothing, and had recently started acting out at home and school. From there, their paths diverged.

One mom took her child, 5-year-old Bradley, to see Kenneth Zucker, a psychologist who had founded one of the first gender identity clinics catering to adolescents, the Centre for Addiction and Mental Health in Toronto. Zucker was an early adopter of the so-called Dutch model, which recommends giving teenagers with gender dysphoria drugs to block puberty. These medications are reversible, so they essentially buy time: The adolescent can decide to stop taking them and go through puberty as the gender they were assigned at birth; or, after a couple of years, they can choose to continue their medical transition by starting estrogen or testosterone.

Although he was one of the most prolific scientists studying gender, Zucker had recently come under fire for his approach to younger kids, which steered them away from a new gender identity and instead attempted to make them feel comfortable in the genders they were assigned at birth. Some of his critics likened his methods to “conversion therapy,” the infamously discredited attempts to undo homosexuality.

Bradley’s mom told NPR that Zucker recommended he play more with boys rather than the mostly girl friends he had at the time. Zucker said they should try to swap his rainbow unicorns and Polly Pockets for more boyish toys, and discourage him from drawing princesses and fairies, or from playing girl characters during make-believe.

Two thousand miles away, in San Francisco, 5-year-old Jonah saw gender specialist Diane Ehrensaft, then a psychologist in Oakland who was touting a new and drastically different approach. Ehrensaft insisted that the label of “gender identity disorder” — or any therapy to treat it — was inappropriate for Jonah. Instead, she said, Jonah was acting out because of years of frustration over not being able to present as a girl. Ehrensaft recommended a full social transition, and Jonah started kindergarten as a girl named Jona.

In separate interviews with NPR reporter Alix Spiegel, Zucker and Ehrensaft openly denounced the other’s approach. Ehrensaft saw gender identity as strongly innate and believed that kids as young as 2 or 3 could begin to express it. “I think that our gender identity is not defined by what’s between our legs but by what’s between our ears — that it’s somewhere in the brain,” she said. “It’s pretty much hardwired.”

Zucker argued that this view was “astonishingly naive and simplistic” — a new form of gender essentialism disguised as progressivism. He instead saw a child’s gender identity as malleable, shaped largely by the family environment.

The crux of the argument came down to what happens to these kids when they grow up. In the interview, Zucker cited one of his studies of 25 kids raised as girls but then diagnosed with gender identity disorder, which found that only 3, or about 12%, kept the diagnosis into adulthood, whereas the rest “desisted.” What’s more, Zucker found that 6 of the 25 grew up to be bisexual or homosexual. Several other studies of “behaviorally feminine” boys had gotten similar results. If these kids had followed Ehrensaft’s methods, Zucker said, they could have been wrongly sent down a track of hormone therapies and surgeries.

The crux of the argument came down to what happens to these kids when they grow up.

At the time of the interview, most doctors in the US agreed with Zucker. But in the eight years since, a huge shift has happened, says Ehrensaft, who now runs a gender-affirming clinic at the University of California, San Francisco. “You ask me now, and I say ours is absolutely the ascendant and increasingly predominant model for treating gender-nonconforming children, accepted throughout the world.”

(Zucker declined multiple requests for interviews from BuzzFeed News, instead sending five of his published papers on gender dysphoria in kids.)

Ehrensaft rejects the high desistance rates reported by Zucker and other researchers, cited repeatedly in arguments against social transitioning in kids. The biggest flaw in these studies, she says, was how they decided which kids to recruit. The children chosen showed a wide spectrum of gender-nonconforming behaviors that may have made parents uncomfortable at the time, but aren’t reliable markers of kids with lasting gender dysphoria. Those kids, Ehrensaft says, have the “insistent, consistent, and persistent” belief that they are another gender. What’s more, some of the studies assumed that teens who didn’t come back for follow-ups had desisted.

Since 2011, Ehrensaft’s clinic has seen about 100 children under 12. The kids are encouraged to choose from a huge array of gender labels, such as “gender hybrid,” “gender fluid,” “gender smoothie,” “gender Tesla,” and “gender Tootsie Roll pop.” Yet another category, “transgender” children, identify with the gender opposite what is marked on their birth certificates. Ehrensaft acknowledges that creating more labels might seem counterintuitive, but argues that they’re useful in making all kids — transgender or anything else — feel comfortable with the diversity of unique gender experiences out there. “Our clinical observation to date is that this is a very well-working model,” Ehrensaft said.

But she’s the first to admit that the approach hasn’t been tested in the long term. No study has yet looked at whether young kids who socially transition continue to thrive as transgender adults.

For the two kids in the radio segment, Zucker’s and Ehrensaft’s predictions seemed to play out as they each expected. Today, Bradley is a teenage boy who identifies as gay. (According to a recent interview with his mother, she said she appreciated Zucker’s “protective” approach.)

Jona, too, is doing well, according to Ehrensaft. “The most I can tell you about Jona without violating confidentiality is that she is doing beautifully eight years later.”